START WORK NOTIFICATION

Transcription

1 START WORK NOTIFICATION This form must be submitted at least 3 buisness days before beginning work to the Rhode Island Department of Health by at leadprogram@health.ri.gov or by fax at Type of License (check one) Lead Hazard Reduction Contractor OR Lead Hazard Control Firm (check all that apply): -> Renovate Right pamphlet distributed -> Confirmation of receipt of Form PBLC -29 on file TYPE OF NOTIFICATION: ( Check one) Original Revised Cancelled Project Schedule: Start Date End Date Lead Hazard Premises: Occupant Name: Street Address: City & Zip Code: Owner Information Names: Floor(s)/Apt.(s)/Area(s) Check if address is same as Lead Hazard Premises above (skip to next section) Street: City, State, Zip Code: Phone: Other Contact: LEAD HAZARD CONTROL / REDUCTION ACTIVITY: (Check ALL that apply) Interior Paint Exterior Paint Common Area Vacant Unit Occupied Unit Child Care Facility Mechanical Paint Removal Other Government Agency Information: Lead Hazard Control / Reduction Ordered by Government Not Applicable (skip to next section) Agency: Person Issuing: Title: Date Ordered Issue: Final Compliance Date Required by Order: Firm Information: Firm Name: Street Address: City, State, Zip Code: Phone: RI License Number: Certifying Lead Hazard Reduction Site Supervisor or Lead-Safe Remodelor/ Renovator I certify that the above information is correct. Print Name Date: RI License No: Signature FORM PBLC-9 (04/2010) PREVIOUS EDITIONS OBSOLETE

2 Rhode Island Pre-Renovation Education and Renovation, Repair and Painting Owner/Occupant Notification Form Occupant Confirmation of Pamphlet Receipt I have received a copy of the pamphlet, Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools informing me of the potential risks of lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the work began. Recipient's Name Date Recipient's Signature Date Street Address, Apartment Number City & Zip Code Lead-Safe Remodeler/Renovator Self Certification option (for tenant occupied dwellings only) If the lead hazard information pamphlet was delivered but a signature could not be obtained, you MUST a check the box below. Declined - I certify that I made a good faith effort to deliver the Renovate Right pamphlet to the rental dwelling unit listed below at the date & time indicated and that the occupant declined to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with the occupant. Unavailable for signature - I certify that I have made a good faith effort to deliver the Renovate Right pamphlet to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by (fill in how the pamphlet was left). Printed Name of Person Certifying Delivery Attempted Delivery Date and Time Signature of Person Certifying Delivery Date Street Address, Apartment Number City Note Regarding Mailing Option - As an alternative to delivery in person, you may mail the lead hazard information pamphlet to the owner and occupant. Pamphlet must be mailed at least 7 days before renovation. Mailing must be documented by a certificate of mailing from the post office. Rhode Island Clearance Inspection Requirement - The Lead Hazard Control Firm or the property owner is required to hire a Rhode Island Certified Environmental Lead Inspector or Technician to conduct clearance inspection using dust wipe sampling and, if applicable, obtain a Certificate of Acceptable Clearance Status or Certification of Lead-Safe Status. Critical barriers cannot be removed until dust wipe samples, analyzed by an approved laboratory, pass clearance. The Lead Hazard Control firm must receive a copy of the clearance certification and retain the certification with this form in its records for at least 3 years. The property owner must receive and retain copies of all certifications, inspections and laboratory reports for as long as he/she owns the property. Clearance Inspection Certification I certify that I informed the property owner of the clearance inspection requirement The Owner or Lead Hazard Control Firm will arrange for the clearance inspection and applicable certification(s). Owner's Name: Owner's Signature: Date: Lead Hazard Control Firm License No. LHCF - Lead-Safe Remodeler/Renovator License No. LRM - Lead-Safe Remodeler/Renovator's Signature Date PBLC-29 (04/2010)

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4 Name of Firm: Date and Location of Renovation: Brief Description of Renovation: EPA Checklist Name of Assigned Renovator: Name of Trained Workers,if used: Name of Dust Sampling Technician, Inspector, or Risk Assessor, if used: Copies of renovator and dust sampling technician qualifications( training certificates, certifications) on file. Certified renovator provided training to workers on (check all that apply) Post warning signs Setting up plastic containment barriers Maintaining containment Avoiding spread of dust to adjacent areas Waste handling Post-renovation cleaning Test kits used by certified renovator to determine whether lead was present on components affected by renovation ( identify kits used and describe sampling locations and results): Warning signs posted at the entrance to the work area. Work area contained to prevent the spread of dust and debris. All objects in the work area removed or covered. (interiors) HVAC ducts in the work area closed. (interiors) Windows in the work area closed. (interiors) Windows in and within 20 feet of the work area closed. (exteriors) Doors in the work area closed and sealed.(interiors) Doors in and within 20 feet of the work area closed and sealed. (exteriors) Doors that must be used in the work area covered to allow passage but prevent spread of dust Floors in the work area covered with taped-down plastic. (interiors) Ground covered by plastic extending 10 feet from the work area - plastic anchored to the building and weighted down by heavy objects. (exteriors) If necessary, vertical containment installed to prevent mitigation of dust and debris to adjacent properties. (exteriors) Waste contained on-site and while being transported off site. Work site properly cleaned after renovation. All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for removal Work area surfaces and objects cleaned using HEPA vacum and/ or wet cloths or mops. (interior) If dust clearance testing was performed instead, attach a copy of the report. I certify under penalty of law that the above information is tru and complete. (Sign) Name and Title Date

5 NOTIFICATION OF REMOVAL OF LEAD BASED PAINT (Required 5 days in advance of starting date) Please be advised that lead based paint is about to be removed from the exterior of a structure at the address below. Address RI City/Town Zip State Approximate dates for starting and finishing the project are: From: To: Lead paint removal is to be done by: Company Name RI License Number Name of Responsible Individual RI License Number Address City/Town State Zip Telephone Method(s) to remove the lead based paint will be: The paint which will be removed from this structure contains lead. Exposure to lead is unhealthy, particularly to young children. For a copy of Regulation 24 and a summary of the requirements, check the Regulations section at the Department's website at or call DEM's Office of Technical and Customer Assistance at (401) For information about lead poisoning prevention, call the Department of Health Lead Hotline at (800) Complaints about improper removal: 8:30 a.m. to 4:00 p.m. weekdays DEM Office of Compliance and Inspection (401) At other times DEM Enforcement (401)

6 All requirements of Rhode Island Air Pollution Control Regulation 24 entitled, "Removal of Lead Based Paint from Exterior Surfaces" must be followed by any person (whether a homeowner or a contractor) who removes paint from the exterior of any structure. Regulation 24 and other pertinent information may be obtained from the Regulations section of the DEM's website at or by calling: Department of Environmental Management Office of Technical and Customer Assistance (401) , 8:30 a.m. to 4:00 p.m. weekdays Written notice of the lead paint removal project must be given to the following individuals at least five (5) days prior to starting any exterior lead paint removal: * Adults residing in the structure from which lead paint is being removed, and * Adults in residences located within 50 feet of the structure undergoing lead paint removal, and * Owners, agents or property managers of the structure and/or of any buildings located within 50 feet of the structure undergoing lead paint removal, and * Owners, agents or managers of buisnesses or organizations located in the structure or within 50 feet of the structure undergoing lead paint removal, and * Principals of schools and the chief administrative officer of every school located within 50 feet of the structure undergoing lead paint removal. Request DEM approval to remove lead paint with a power washing/pressure washing equipment, or the use of any method not approved in regulation 24, by contacting DEM's Office of Air Resources at (401) from 8:30 a.m. to 4:00 p.m. weekdays. Lead paint removal by any procedure considered an alternative procedure, or from structuresother than buildings, must not begin until a written approval is issued by DEM's Office ofair Resources. Questions about disposal of hazardous waste may be directed to DEM's Office of Technical and Customer Assistance (401) from 8:30 a.m. to 4:00 p.m. weekdays. Contractors: Supplemental Information For information about worker protection, contact Providence Area OSHA at (401)